Personal Automobile Glass Claim Request Form

Glass Claim Contact Information

What is your first name?

What is your last name?

What is your email address?

What is the preferred phone number for this glass claim?

Will you be the primary contact for this glass claim?

Yes
No

Who will the primary contact be?

What is their phone number?

What is their email address?

Glass Information

What is the year, make and model of the vehicle with glass damage?

Year	Make	Model

How many doors does this vehicle have?

Does this vehicle have any advanced driver assistance systems?

Does this vehicle have any advanced driver assistance systems(ADAS)? (Ex. Forward collision warning,  lane departure warning, blind spot warning light, and  adaptive cruise control)

Yes
No
Not sure

What is the address where this vehicle is garaged?

Street Address Address Line 2 City State ZIP Code

What date did you first noticed the glass damage?

Please select the damaged glass type(s). (Select all that apply)

Windshield
Side window
Rear window
Other

What other type of glass was damaged?

Please upload a picture of the full pane of damaged glass.

Max. file size: 128 MB.

Please provide a brief description of what caused the damage.

Has the glass already been repaired?

Yes
No

Please upload a copy of the invoice for the repairs.

Max. file size: 128 MB.

Please select the appropriate payment method for this glass claim.

I already paid the invoice. Have insurer reimburse me directly.
Have insurer handle the invoice directly with the repair facility.
Not sure

Glass Repair Preferences

What is your preferred repair solution? (Conditions may apply)

Repair at my home
Repair at my office
Repair at the dealership
Auto glass Shop

What is your office address?

Street Address Address Line 2 City State ZIP Code

Does your office have an enclosed area that provides protection from the weather where repairs can be done?

Yes
No
Not sure

What is the name of the dealership?

What is the dealership's phone number?

What is the address of the dealership?

Street Address Address Line 2 City State ZIP Code

What is the name of the auto glass shop?

What is the auto glass shop's phone number?

What is the address of the auto glass shop?

Street Address Address Line 2 City State ZIP Code

What is the address of the other location where you would like to conduct the glass repair(s)?

Street Address Address Line 2 City State ZIP Code

Comments

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Uploaded Documents

Please use this field to upload any other relevant information for this new residence. (i.e. mortgage requirements, elevation certificates, wind mitigation form, etc.).

Drop files here or

Max. file size: 128 MB.

Please enter any additional remarks in the space below.

Consent*

Disclaimers: Any claim handling preferences selected in this form may not be available for this claim. Repair procedures will be determined by auto glass repair professionals, type of glass being repaired and other applicable conditions.

This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.

Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.

I agree

Personal Automobile Glass Claim Request Form

Glass Claim Contact Information

Glass Information

Glass Repair Preferences

Comments

Kurt Thoennessen, CAPI

RiskRevu^TM Newsletter

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Personal Automobile Glass Claim Request Form

Glass Claim Contact Information

Glass Information

Glass Repair Preferences

Comments

Kurt Thoennessen, CAPI

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RiskRevuTM Newsletter

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RiskRevu^TM Newsletter